/*jslint nomen:false, debug:true, evil:true, vars:false, browser:true, forin:true, undef:false, white:false */
/**
 * Includes a Form with javascript
 * @param {Object} formId
 * @param {Object} initialHeight
 * @param {Object} iframeCode
 */
function FrameBuilder (formId, appendTo, initialHeight, iframeCode){
    this.formId = formId;
    this.initialHeight = initialHeight;
    this.iframeCode = iframeCode;
    this.frame = null;
    this.timeInterval= 200;
    this.appendTo = appendTo || false;
    
    // initialize function for object
    this.init = function(){
        this.createFrame();
        this.addFrameContent(this.iframeCode);
    };
    
    // Create the frame
    this.createFrame = function(){
        var htmlCode = "<"+"iframe src=\"\" allowtransparency=\"true\" frameborder=\"0\" name=\""+this.formId+"\" id=\""+this.formId+"\" style=\"width:100%; height:"+this.initialHeight+"px; border:none;\" scrolling=\"no\"></if"+"rame>";
        if(this.appendTo === false){
            document.write(htmlCode);
        }else{
            var tmp = document.createElement('div');
            tmp.innerHTML = htmlCode;
            var a = this.appendTo;
            document.getElementById(a).appendChild(tmp.firstChild);            
        }
        // also get the frame for future use.
        this.frame = document.getElementById(this.formId);
        // set the time on the on load event of the frame
        this.addEvent(this.frame, 'load', this.bindMethod(this.setTimer, this));
    };
    
    // add event function for different browsers
    this.addEvent = function( obj, type, fn ) {
        if ( obj.attachEvent ) {
            obj["e"+type+fn] = fn;
            obj[type+fn] = function() { obj["e"+type+fn]( window.event ); };
            obj.attachEvent( "on"+type, obj[type+fn] );
        }
        else{
            obj.addEventListener( type, fn, false );   
        }
    };
    
    this.addFrameContent = function (string){
        string = string.replace(new RegExp('src\\=\\"[^"]*captcha.php\"><\/scr'+'ipt>', 'gim'), 'src="http://api.recaptcha.net/js/recaptcha_ajax.js"></scr'+'ipt><'+'div id="recaptcha_div"><'+'/div>'+
                '<'+'style>#recaptcha_logo{ display:none;} #recaptcha_tagline{display:none;} #recaptcha_table{border:none !important;} .recaptchatable .recaptcha_image_cell, #recaptcha_table{ background-color:transparent !important; } <'+'/style>'+
                '<'+'script defer="defer"> window.onload = function(){ Recaptcha.create("6Ld9UAgAAAAAAMon8zjt30tEZiGQZ4IIuWXLt1ky", "recaptcha_div", {theme: "clean",tabindex: 0,callback: function (){'+
                'if (document.getElementById("uword")) { document.getElementById("uword").parentNode.removeChild(document.getElementById("uword")); } if (window["validate"] !== undefined) { if (document.getElementById("recaptcha_response_field")){ document.getElementById("recaptcha_response_field").onblur = function(){ validate(document.getElementById("recaptcha_response_field"), "Required"); } } } if (document.getElementById("recaptcha_response_field")){ document.getElementsByName("recaptcha_challenge_field")[0].setAttribute("name", "anum"); } if (document.getElementById("recaptcha_response_field")){ document.getElementsByName("recaptcha_response_field")[0].setAttribute("name", "qCap"); }}})'+
                ' }<'+'/script>');
        string = string.replace(/(type="text\/javascript">)\s+(validate\(\"[^"]*"\);)/, '$1 jTime = setInterval(function(){if("validate" in window){$2clearTimeout(jTime);}}, 1000);');
        var frameDocument = (this.frame.contentWindow) ? this.frame.contentWindow : (this.frame.contentDocument.document) ? this.frame.contentDocument.document : this.frame.contentDocument;
        frameDocument.document.open();
        frameDocument.document.write(string);
        setTimeout( function(){
            frameDocument.document.close();
            try{
                if('JotFormFrameLoaded' in window){
                    JotFormFrameLoaded();
                }
            }catch(e){}
        },200);
    };
    
    this.setTimer = function(){
        var self = this;
        this.interval = setTimeout(function(){self.changeHeight();},this.timeInterval);
    };
    
    this.changeHeight = function (){
        var actualHeight = this.getBodyHeight();
        var currentHeight = this.getViewPortHeight();
        if(actualHeight === undefined){
            this.frame.style.height = "100%";
            if(!this.frame.style.minHeight){
                this.frame.style.minHeight = "300px";
            }
        }else if  (Math.abs(actualHeight - currentHeight) > 18){
            this.frame.style.height = (actualHeight)+"px";
        }
        this.setTimer();
    };
    
    this.bindMethod = function(method, scope) {
        return function() {
            method.apply(scope,arguments);
        };
    };
    
    this.getBodyHeight = function (){
        var height;
        var scrollHeight;
        var offsetHeight;
        try{  // Prevent IE from throw errors
            if (this.frame.contentWindow.document.height){
                
                height = this.frame.contentWindow.document.height;
                //Emre: to prevent "iframe height"  problem (61059)
                if (this.frame.contentWindow.document.body.scrollHeight){
                    height = scrollHeight = this.frame.contentWindow.document.body.scrollHeight;
                }
                
                if (this.frame.contentWindow.document.body.offsetHeight){
                    height = offsetHeight = this.frame.contentWindow.document.body.offsetHeight;
                }
                
            } else if (this.frame.contentWindow.document.body){
                
                if (this.frame.contentWindow.document.body.scrollHeight){
                    height = scrollHeight = this.frame.contentWindow.document.body.scrollHeight;
                }
                
                if (this.frame.contentWindow.document.body.offsetHeight){
                    height = offsetHeight = this.frame.contentWindow.document.body.offsetHeight;
                }
                
                if (scrollHeight && offsetHeight){
                    height = Math.max(scrollHeight, offsetHeight);
                }
            }            
        }catch(e){ }
        return height;
    };
    
    this.getViewPortHeight = function(){
        var height = 0;
        try{ // Prevent IE from throw errors
            if (this.frame.contentWindow.window.innerHeight)
            {
                height = this.frame.contentWindow.window.innerHeight - 18;
            }
            else if ((this.frame.contentWindow.document.documentElement) &&
                     (this.frame.contentWindow.document.documentElement.clientHeight))
            {
                height = this.frame.contentWindow.document.documentElement.clientHeight;
            }
            else if ((this.frame.contentWindow.document.body) &&
                     (this.frame.contentWindow.document.body.clientHeight))
            {
                height = this.frame.contentWindow.document.body.clientHeight;
            }            
        }catch(e){ }
        return height;
    };
    
    this.init();
}
FrameBuilder.get = [];
var i1475015226 = new FrameBuilder("1475015226", false, "", "<!DOCTYPE HTML PUBLIC \"-\/\/W3C\/\/DTD HTML 4.01\/\/EN\" \"http:\/\/www.w3.org\/TR\/html4\/strict.dtd\">\n<html><head>\n<meta http-equiv=\"Content-Type\" content=\"text\/html; charset=utf-8\" \/>\n<meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0, maximum-scale=1.0, user-scalable=0\" \/>\n<meta name=\"HandheldFriendly\" content=\"true\" \/>\n<title>Form<\/title>\n<link href=\"http:\/\/max.jotfor.ms\/min\/g=formCss?3.0.2419\" rel=\"stylesheet\" type=\"text\/css\" \/>\n<style type=\"text\/css\">\n    .form-label{\n        width:300px !important;\n    }\n    .form-label-left{\n        width:300px !important;\n    }\n    .form-line{\n        padding:10px;\n    }\n    .form-label-right{\n        width:300px !important;\n    }\n    body, html{\n        margin:0;\n        padding:0;\n        background:false;\n    }\n\n    .form-all{\n        margin:0px auto;\n        padding-top:0px;\n        width:375px;\n        color:Black !important;\n        font-family:Verdana;\n        font-size:12px;\n    }\n<\/style>\n\n<script src=\"http:\/\/max.jotfor.ms\/min\/g=jotform?3.0.2419\" type=\"text\/javascript\"><\/script>\n<script type=\"text\/javascript\">\n var jsTime = setInterval(function(){try{\n   JotForm.jsForm = true;\n\n   JotForm.init(function(){\n      $('input_31').hint('ex: myname@example.com');\n   });\n\n   clearInterval(jsTime);\n }catch(e){}}, 1000);\n<\/script>\n<\/head>\n<body>\n<form class=\"jotform-form\" action=\"http:\/\/submit.jotform.com\/submit.php\" method=\"post\" name=\"form_1475015226\" id=\"1475015226\" accept-charset=\"utf-8\">\n  <input type=\"hidden\" name=\"formID\" value=\"1475015226\" \/>\n  <div class=\"form-all\">\n    <ul class=\"form-section\">\n      <li id=\"cid_3\" class=\"form-input-wide\">\n        <div class=\"form-header-group\">\n          <h2 id=\"header_3\" class=\"form-header\">\n            Home Healthcare Assessment\n          <\/h2>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" id=\"id_4\">\n        <div id=\"cid_4\" class=\"form-input-wide\">\n          <div id=\"text_4\" class=\"form-html\">\n            <P>\n              We can't help but be concerned about those we care about \u2026 especially when they&nbsp;&nbsp; are getting older or have just experienced an illness, incident, or hospital&nbsp;&nbsp; stay. Many wonder if they are just being overprotective \u2026 or if their loved one&nbsp;&nbsp; really does need assistance. The Care Assessment below offers you the&nbsp;&nbsp; opportunity to see if your worries are justified, looking at specific issues of&nbsp;&nbsp; everyday living. Use this for your benefit, or e-mail\n              it to us to receive our&nbsp;&nbsp; initial suggestions based upon your response.\n            <\/P>\n            <P>\n              <BR>\n              &nbsp;\n              <FONT size=2 face=\"Arial, Helvetica, sans-serif\">\n                <A href=\"assessment.pdf\" target=_blank><STRONG>Click here to download a PDF version of the form.<\/STRONG><\/A><\/FONT><BR><\/P>\n                <P><BR>&nbsp; If your concerns are unjustified, we hope we&nbsp;&nbsp; can ease your mind. If we feel that your loved one truly needs assistance, we&nbsp;&nbsp; are happy to provide you with specifically how we can help.<BR><\/P><\/div> <\/div><\/li><li class=\"form-line\" id=\"id_5\" ><label class=\"form-label-left\" id=\"label_5\" for=\"input_5\"> 1. Is your loved one currently taking any medication? <\/label><div id=\"cid_5\" class=\"form-input\"> <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_5_0\" name=\"q5_1Is5\"  value=\"Yes\" \/><label for=\"input_5_0\">Yes<\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_5_1\" name=\"q5_1Is5\"  value=\"No\" \/><label for=\"input_5_1\">No<\/label><\/span><span class=\"clearfix\"><\/span><\/div> <\/div><\/li><li class=\"form-line\" id=\"id_6\" ><label class=\"form-label-left\" id=\"label_6\" for=\"input_6\"> a. If so, are they able to fully understand and follow the prescription instructions? <\/label><div id=\"cid_6\" class=\"form-input\"> <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_6_0\" name=\"q6_aIf\"  value=\"Yes\" \/><label for=\"input_6_0\">Yes<\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_6_1\" name=\"q6_aIf\"  value=\"No\" \/><label for=\"input_6_1\">No<\/label><\/span><span class=\"clearfix\"><\/span><\/div> <\/div><\/li><li class=\"form-line\" id=\"id_7\" ><label class=\"form-label-left\" id=\"label_7\" for=\"input_7\"> b. Are you very confident that they are taking the correct dosage at the correct time? <\/label><div id=\"cid_7\" class=\"form-input\"> <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_7_0\" name=\"q7_bAre\"  value=\"Yes\" \/><label for=\"input_7_0\">Yes<\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_7_1\" name=\"q7_bAre\"  value=\"No\" \/><label for=\"input_7_1\">No<\/label><\/span><span class=\"clearfix\"><\/span><\/div> <\/div><\/li><li class=\"form-line\" id=\"id_8\" ><label class=\"form-label-left\" id=\"label_8\" for=\"input_8\"> c. Could this medication that they are taking affect their physical or mental state if avoided or taken in excess? <\/label><div id=\"cid_8\" class=\"form-input\"> <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_8_0\" name=\"q8_cCould8\"  value=\"Yes\" \/><label for=\"input_8_0\">Yes<\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_8_1\" name=\"q8_cCould8\"  value=\"No\" \/><label for=\"input_8_1\">No<\/label><\/span><span class=\"clearfix\"><\/span><\/div> <\/div><\/li><li class=\"form-line\" id=\"id_9\" ><label class=\"form-label-left\" id=\"label_9\" for=\"input_9\"> 2. Does your loved one follow recommendations given by their physician? <\/label><div id=\"cid_9\" class=\"form-input\"> <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_9_0\" name=\"q9_2Does\"  value=\"Yes\" \/><label for=\"input_9_0\">Yes<\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_9_1\" name=\"q9_2Does\"  value=\"No\" \/><label for=\"input_9_1\">No<\/label><\/span><span class=\"clearfix\"><\/span><\/div> <\/div><\/li><li class=\"form-line\" id=\"id_10\" ><label class=\"form-label-left\" id=\"label_10\" for=\"input_10\"> 3. Is your loved one able to drive or walk to obtain necessary home supplies, i.e. groceries, soap, medicine? <\/label><div id=\"cid_10\" class=\"form-input\"> <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_10_0\" name=\"q10_3Is\"  value=\"Yes\" \/><label for=\"input_10_0\">Yes<\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_10_1\" name=\"q10_3Is\"  value=\"No\" \/><label for=\"input_10_1\">No<\/label><\/span><span class=\"clearfix\"><\/span><\/div> <\/div><\/li><li class=\"form-line\" id=\"id_11\" ><label class=\"form-label-left\" id=\"label_11\" for=\"input_11\"> 4. If above is answered \"No\", is there a reliable system set in place to assure that your loved one has basic home needs met? <\/label><div id=\"cid_11\" class=\"form-input\"> <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_11_0\" name=\"q11_4If\"  value=\"Yes\" \/><label for=\"input_11_0\">Yes<\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_11_1\" name=\"q11_4If\"  value=\"No\" \/><label for=\"input_11_1\">No<\/label><\/span><span class=\"clearfix\"><\/span><\/div> <\/div><\/li><li class=\"form-line\" id=\"id_12\" ><label class=\"form-label-left\" id=\"label_12\" for=\"input_12\"> 5. Is your loved one able to answer the telephone without inconvenience? <\/label><div id=\"cid_12\" class=\"form-input\"> <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_12_0\" name=\"q12_5Is\"  value=\"Yes\" \/><label for=\"input_12_0\">Yes<\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_12_1\" name=\"q12_5Is\"  value=\"No\" \/><label for=\"input_12_1\">No<\/label><\/span><span class=\"clearfix\"><\/span><\/div> <\/div><\/li><li class=\"form-line\" id=\"id_13\" ><label class=\"form-label-left\" id=\"label_13\" for=\"input_13\"> 6. Is your loved one able to make phone calls out at anytime of the day or night? <\/label><div id=\"cid_13\" class=\"form-input\"> <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_13_0\" name=\"q13_6Is\"  value=\"Yes\" \/><label for=\"input_13_0\">Yes<\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_13_1\" name=\"q13_6Is\"  value=\"No\" \/><label for=\"input_13_1\">No<\/label><\/span><span class=\"clearfix\"><\/span><\/div> <\/div><\/li><li class=\"form-line\" id=\"id_14\" ><label class=\"form-label-left\" id=\"label_14\" for=\"input_14\"> 7. Is your loved one able to pay bills, such as power and water, in an accurate and timely manner? <\/label><div id=\"cid_14\" class=\"form-input\"> <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_14_0\" name=\"q14_7Is\"  value=\"Yes\" \/><label for=\"input_14_0\">Yes<\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_14_1\" name=\"q14_7Is\"  value=\"No\" \/><label for=\"input_14_1\">No<\/label><\/span><span class=\"clearfix\"><\/span><\/div> <\/div><\/li><li class=\"form-line\" id=\"id_15\" ><label class=\"form-label-left\" id=\"label_15\" for=\"input_15\"> 8. Does your loved one have a neighbor, friend, or family member close-by that is willing, able, and accessible to assist your loved one in person if called upon? <\/label><div id=\"cid_15\" class=\"form-input\"> <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_15_0\" name=\"q15_8Does\"  value=\"Yes\" \/><label for=\"input_15_0\">Yes<\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_15_1\" name=\"q15_8Does\"  value=\"No\" \/><label for=\"input_15_1\">No<\/label><\/span><span class=\"clearfix\"><\/span><\/div> <\/div><\/li><li class=\"form-line\" id=\"id_16\" ><label class=\"form-label-left\" id=\"label_16\" for=\"input_16\"> 9. Is your loved one able to prepare their meals on their own? <\/label><div id=\"cid_16\" class=\"form-input\"> <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_16_0\" name=\"q16_9Is\"  value=\"Yes\" \/><label for=\"input_16_0\">Yes<\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_16_1\" name=\"q16_9Is\"  value=\"No\" \/><label for=\"input_16_1\">No<\/label><\/span><span class=\"clearfix\"><\/span><\/div> <\/div><\/li><li class=\"form-line\" id=\"id_17\" ><label class=\"form-label-left\" id=\"label_17\" for=\"input_17\"> a. If so, are you concerned that they are getting the proper nutrition given what they are preparing? <\/label><div id=\"cid_17\" class=\"form-input\"> <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_17_0\" name=\"q17_aIf17\"  value=\"Yes\" \/><label for=\"input_17_0\">Yes<\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_17_1\" name=\"q17_aIf17\"  value=\"No\" \/><label for=\"input_17_1\">No<\/label><\/span><span class=\"clearfix\"><\/span><\/div> <\/div><\/li><li class=\"form-line\" id=\"id_18\" ><label class=\"form-label-left\" id=\"label_18\" for=\"input_18\"> b. Is there a chance that a burner or oven could be left on when preparing meals? <\/label><div id=\"cid_18\" class=\"form-input\"> <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_18_0\" name=\"q18_bIs\"  value=\"Yes\" \/><label for=\"input_18_0\">Yes<\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_18_1\" name=\"q18_bIs\"  value=\"No\" \/><label for=\"input_18_1\">No<\/label><\/span><span class=\"clearfix\"><\/span><\/div> <\/div><\/li><li class=\"form-line\" id=\"id_19\" ><label class=\"form-label-left\" id=\"label_19\" for=\"input_19\"> 10. Does your loved one tend to get weaker when they get tired? <\/label><div id=\"cid_19\" class=\"form-input\"> <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_19_0\" name=\"q19_10Does\"  value=\"Yes\" \/><label for=\"input_19_0\">Yes<\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_19_1\" name=\"q19_10Does\"  value=\"No\" \/><label for=\"input_19_1\">No<\/label><\/span><span class=\"clearfix\"><\/span><\/div> <\/div><\/li><li class=\"form-line\" id=\"id_20\" ><label class=\"form-label-left\" id=\"label_20\" for=\"input_20\"> 11. Is your loved one able to bathe themself independently? <\/label><div id=\"cid_20\" class=\"form-input\"> <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_20_0\" name=\"q20_11Is\"  value=\"Yes\" \/><label for=\"input_20_0\">Yes<\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_20_1\" name=\"q20_11Is\"  value=\"No\" \/><label for=\"input_20_1\">No<\/label><\/span><span class=\"clearfix\"><\/span><\/div> <\/div><\/li><li class=\"form-line\" id=\"id_21\" ><label class=\"form-label-left\" id=\"label_21\" for=\"input_21\"> 12. Do you feel comfortable with their bathing facilities? <\/label><div id=\"cid_21\" class=\"form-input\"> <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_21_0\" name=\"q21_12Do\"  value=\"Yes\" \/><label for=\"input_21_0\">Yes<\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_21_1\" name=\"q21_12Do\"  value=\"No\" \/><label for=\"input_21_1\">No<\/label><\/span><span class=\"clearfix\"><\/span><\/div> <\/div><\/li><li class=\"form-line\" id=\"id_22\" ><label class=\"form-label-left\" id=\"label_22\" for=\"input_22\"> 13. Is your loved one able to successfully use the bathroom independently? <\/label><div id=\"cid_22\" class=\"form-input\"> <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_22_0\" name=\"q22_13Is\"  value=\"Yes\" \/><label for=\"input_22_0\">Yes<\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_22_1\" name=\"q22_13Is\"  value=\"No\" \/><label for=\"input_22_1\">No<\/label><\/span><span class=\"clearfix\"><\/span><\/div> <\/div><\/li><li class=\"form-line\" id=\"id_23\" ><label class=\"form-label-left\" id=\"label_23\" for=\"input_23\"> 14. Are they able to either do laundry or coordinate laundry services? <\/label><div id=\"cid_23\" class=\"form-input\"> <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_23_0\" name=\"q23_14Are\"  value=\"Yes\" \/><label for=\"input_23_0\">Yes<\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_23_1\" name=\"q23_14Are\"  value=\"No\" \/><label for=\"input_23_1\">No<\/label><\/span><span class=\"clearfix\"><\/span><\/div> <\/div><\/li><li class=\"form-line\" id=\"id_24\" ><label class=\"form-label-left\" id=\"label_24\" for=\"input_24\"> 15. Are you ever concerned about your loved one's appearance, i.e. hair, dress, oral hygiene? <\/label><div id=\"cid_24\" class=\"form-input\"> <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_24_0\" name=\"q24_15Are\"  value=\"Yes\" \/><label for=\"input_24_0\">Yes<\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_24_1\" name=\"q24_15Are\"  value=\"No\" \/><label for=\"input_24_1\">No<\/label><\/span><span class=\"clearfix\"><\/span><\/div> <\/div><\/li><li class=\"form-line\" id=\"id_25\" ><label class=\"form-label-left\" id=\"label_25\" for=\"input_25\"> 16. Does the physical layout of your loved one's home, i.e. stairs, decorations, rugs, cause you to be concerned about safety? <\/label><div id=\"cid_25\" class=\"form-input\"> <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_25_0\" name=\"q25_16Does\"  value=\"Yes\" \/><label for=\"input_25_0\">Yes<\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_25_1\" name=\"q25_16Does\"  value=\"No\" \/><label for=\"input_25_1\">No<\/label><\/span><span class=\"clearfix\"><\/span><\/div> <\/div><\/li><li class=\"form-line\" id=\"id_26\" ><label class=\"form-label-left\" id=\"label_26\" for=\"input_26\"> 17. Have you noticed any memory loss with your loved one? <\/label><div id=\"cid_26\" class=\"form-input\"> <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_26_0\" name=\"q26_17Have\"  value=\"Yes\" \/><label for=\"input_26_0\">Yes<\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_26_1\" name=\"q26_17Have\"  value=\"No\" \/><label for=\"input_26_1\">No<\/label><\/span><span class=\"clearfix\"><\/span><\/div> <\/div><\/li><li class=\"form-line\" id=\"id_27\" ><label class=\"form-label-left\" id=\"label_27\" for=\"input_27\"> 18. If above is answered \"Yes\", does this seem to be increasing or decreasing? <\/label><div id=\"cid_27\" class=\"form-input\"> <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_27_0\" name=\"q27_18If\"  value=\"Yes\" \/><label for=\"input_27_0\">Yes<\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_27_1\" name=\"q27_18If\"  value=\"No\" \/><label for=\"input_27_1\">No<\/label><\/span><span class=\"clearfix\"><\/span><\/div> <\/div><\/li><li class=\"form-line\" id=\"id_28\" ><label class=\"form-label-left\" id=\"label_28\" for=\"input_28\"> 19. Do you sometimes feel that your loved one is not supplying you with accurate or clear information in regard to their own health? <\/label><div id=\"cid_28\" class=\"form-input\"> <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_28_0\" name=\"q28_19Do\"  value=\"Yes\" \/><label for=\"input_28_0\">Yes<\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_28_1\" name=\"q28_19Do\"  value=\"No\" \/><label for=\"input_28_1\">No<\/label><\/span><span class=\"clearfix\"><\/span><\/div> <\/div><\/li><li class=\"form-line\" id=\"id_29\" ><label class=\"form-label-left\" id=\"label_29\" for=\"input_29\"> Full Name <\/label><div id=\"cid_29\" class=\"form-input\"><span class=\"form-sub-label-container\"><input class=\"form-textbox\" type=\"text\" size=\"10\" name=\"q29_fullName29[first]\" id=\"first_29\" \/>  <label class=\"form-sub-label\" for=\"first_29\" id=\"sublabel_first\">First Name<\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox\" type=\"text\" size=\"15\" name=\"q29_fullName29[last]\" id=\"last_29\" \/> <label class=\"form-sub-label\" for=\"last_29\" id=\"sublabel_last\">Last Name<\/label><\/span> <\/div><\/li><li class=\"form-line\" id=\"id_31\" ><label class=\"form-label-left\" id=\"label_31\" for=\"input_31\"> E-mail <\/label><div id=\"cid_31\" class=\"form-input\"> <input type=\"email\" class=\"form-textbox validate[Email]\"id=\"input_31\" name=\"q31_email31\" size=\"30\"  \/> <\/div><\/li><li class=\"form-line\" id=\"id_30\" ><label class=\"form-label-left\" id=\"label_30\" for=\"input_30\"> Phone Number <\/label><div id=\"cid_30\" class=\"form-input\"><span class=\"form-sub-label-container\"><input class=\"form-textbox\" type=\"tel\" name=\"q30_phoneNumber[area]\" id=\"input_30_area\" size=\"3\"> - <label class=\"form-sub-label\" for=\"input_30_area\" id=\"sublabel_area\">Area Code<\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox\" type=\"tel\" name=\"q30_phoneNumber[phone]\" id=\"input_30_phone\" size=\"8\"> <label class=\"form-sub-label\" for=\"input_30_phone\" id=\"sublabel_phone\">Phone Number<\/label><\/span> <\/div><\/li><li class=\"form-line\" id=\"id_32\" ><label class=\"form-label-left\" id=\"label_32\" for=\"input_32\"> Your Subject <\/label><div id=\"cid_32\" class=\"form-input\"> <input type=\"text\" class=\"form-textbox\"id=\"input_32\" name=\"q32_yourSubject\" size=\"50\" value=\"Home Healthcare Assessment form\"  \/> <\/div><\/li><li class=\"form-line\" id=\"id_33\" ><label class=\"form-label-left\" id=\"label_33\" for=\"input_33\"> Questions\/Comments: <\/label><div id=\"cid_33\" class=\"form-input\"> <textarea id=\"input_33\" class=\"form-textarea\" name=\"q33_questionscomments\" cols=\"40\" rows=\"6\" ><\/textarea> <\/div><\/li><li class=\"form-line\" id=\"id_2\" ><div id=\"cid_2\" class=\"form-input-wide\"> <div style=\"text-align:left\" class=\"form-buttons-wrapper\"><button id=\"input_2\" type=\"submit\" class=\"form-submit-button\" >Submit Form<\/button> &nbsp; <button id=\"input_reset_2\" type=\"reset\" class=\"form-submit-reset\">Clear Form<\/button><\/div> <\/div><\/li><li class=\"form-line\" id=\"id_34\" ><div id=\"cid_34\" class=\"form-input-wide\"> <div id=\"text_34\" class=\"form-html\">Disclaimer: These questions are designed to help the viewer discover areas that might suggest the need for care or supervison. Please do not presume that the list includes all reasons why supervision may be helpful or necessary.&nbsp;<\/div> <\/div><\/li><li style=\"display:none\">Should be Empty: <input type=\"text\" name=\"website\" value=\"\" \/><\/li><\/ul><\/div><input type=\"hidden\" id=\"simple_spc\" name=\"simple_spc\" value=\"1475015226\"\/><script type=\"text\/javascript\">document.getElementById(\"si\"+\"mple\"+\"_spc\").value = \"1475015226-1475015226\";<\/script><\/form><\/body>\n<\/html>\n");